Prime Minister David Cameron is promising savage spending cuts in the face of the largest deficit in UK history. For this reason, there is keen interest in cost efficient ‘model’ programs to serve the nation’s children.

As part of the Brighter Futures Strategy, the Birmingham City Council is conducting a randomized controlled trial of the Incredible Years (IY) BASIC 12-week Parenting Program. There is distinct need in Birmingham for such a program. Recent studies tell us there are approximately 1500 3-year-olds with conduct problems in the city.

For a proper trial, the Council determined that 144 families needed to be recruited. Those families had to have 3-4 year olds who scored high on the Strengths and Difficulties Questionnaire (Goodman, 1997).

But getting to these families is not easy. The families most in need of services are often the hardest to reach. Child and family services couldn’t rely on the lower hanging fruit on the tree—the families that sought services. They needed to reach for the elusive 10-15% of young children displaying conduct problems.

Targeted interventions are notoriously difficult to both recruit for and to run trials on. Families who are labeled ‘hard, or difficult, to engage’ have earned this label for a reason. Likewise, poor sign up and participation rates threaten the validity of any result. It’s hardly surprising that there has been little research in to this area (Spoth & Redmond, 2000). Those trying to reach and serve these populations have had to set their own benchmarks for ‘what works’.

In Birmingham detailed discussions were conducted between the research team and key stakeholders trying to crack the puzzle of recruitment. Some of the conclusions were rudimentary but necessary. Sites needed to be ‘ready’ to engage with the target population and be willing to deliver the program. Staff must be fully informed of who and what the evaluation involves, and how it links to the Brighter Futures Strategy.

Children Centre staff across Birmingham initially approached families at open days for nursery registration. While the number of families they talked to was high, the approach did not pay huge dividends – from the initial group of referrals only 17% met criteria. The numbers improved over the next few months. Additional referral agencies were included, such as family support workers and nursery nurses, and the eligibility numbers went up %10. This improvement, however, still fell well below similar studies. In Wales, where researchers relied on Health Visitors for referrals, they had 80-90% reaching criteria (Hutchings et al., 2007).

The analysis of the demand in Birmingham was not ‘wrong’ but the targeting strategy was still weak. Further steps were taken to improve recruitment. Referral-to-recruitment timelines were tightened and reduced to a two-week turn-around, and parents were asked about their perceived barriers regarding participation. In general, parents had a number of reasons for resisting the program. They believed they did not need the service or didn’t understand what was being offered. Some thought it would be too demanding. Others did not trust the service or staff or they struggled with language barriers.

Program literature for both parents and staff was revisited and amended to try to allay fears and to highlight the benefits of participation using more accessible ‘friendly’ language. The referral staff also needed further training. Many were under the misconception that that parents who were allocated to the control group would not benefit in any way, which led to a reticence to refer.

But ultimately, the decision was made that more staff was needed to find and recruit the hardest to reach families. These new members prepared and distributed informational DVDs, which highlighted past participants’ experiences. This reduced the workload burden for Children Centre’s main staff, enabling them to spend more time encouraging program attendance after the families had been recruited and figuring out the best way to deliver the program and retain participants in this multi-ethnic, highly diverse UK City.

When expanding an intervention program within any pre-existing service there are many interconnecting components, all of which ideally should be evaluated as the program scales up. The development phase should include a feasibility study to iron out potential referral and recruitment difficulties as the Birmingham City Council experienced. Prevention Action will follow the latest developments in Birmingham’s program as it unfolds.

References

Goodman, R. (1997). The Strengths and Difficulties Questionnaire: A research note. Journal of Child Psychology, Psychiatry, and Allied Disciplines, 38 (5), 581-586.

Hutchings, J., Bywater, T., Daley, D., Gardner, F., Whitaker, C., Jones, K., Eames, C., & Edwards, R.T. (2007). Parenting Intervention in Sure Start Services for Children at Risk of Developing Conduct Disorder: Pragmatic Randomised Controlled Trial. British Medical Journal, doi:10.1136/bmj.39126.620799.55

Spoth, R., Redmond, C, & Shin, C. (2000). Modeling factors influencing enrollment in family-focused preventive intervention research. Prevention Science, 1 (4), 213-225.